In message <001501c440d0$883c3980$0301a8c0@Study>, Andy Lee
<[log in to unmask]> writes
>
>On a related point, have people noticed the proposed NPSA scheme for all NHS
>staff to report 'patient safety incidents' directly to NPSA rather than via
>their Trust/organisation? The NPSA state they will take responsibility for
>removing patient identifiable data at their end.
I find this a bit difficult.
Suppose you are someone who receives a query from the NPSA about an
incident - prescribing, treatment, dispensing, whatever - and all
patient identifiable data has been removed.
*Would* you be able to investigate?
When we had the Significant Event Report regarding dispensing errors
(and I do appreciate Jeff's comment on the problems pharmacists have
with prescriptions) , I had expected that I would be advised that this
was something that should be reported to the NPSA - which I had thought
was already in existence. I must admit I was surprised to get the advice
to discuss each episode with the pharmacy involved.
I always get a positive response from the local pharmacists.
One of the problems - the possibility of confusion between different
doses of thyroxine - appear to have been manufactured by the
manufacturers: these are very small unmarked tablets: whereas they used
to be colour coded, they are all now white...
Shouldn't systems try to *minimise* the risk of error?
Is NPSA a reporting system similar to the airline near miss reporting -
or yet another means of disciplinary action?
MaryH
--
Mary Hawking
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